What is the management approach for acute diverticulitis?

From the Guidelines

The management of acute diverticulitis should prioritize outpatient management for uncomplicated cases, with selective use of antibiotics and a clear liquid diet during the acute phase, as recommended by the American College of Physicians (ACP) in their 2022 guideline 1. The approach to managing acute diverticulitis depends on the severity of the disease, with uncomplicated cases often managed as outpatients and complicated cases requiring hospitalization.

• For uncomplicated diverticulitis, outpatient management is suggested, with the use of antibiotics being conditional, based on low-certainty evidence 1.
• The ACP recommends the use of abdominal CT imaging when there is diagnostic uncertainty in a patient with suspected acute left-sided colonic diverticulitis, due to its high sensitivity and specificity 1.
• Patients with uncomplicated diverticulitis should be advised to follow a clear liquid diet during the acute phase, advancing to low-fiber foods as symptoms improve, as suggested by the AGA clinical practice update 1.
• Pain management with acetaminophen or non-steroidal anti-inflammatory drugs is recommended, with patients having fever >102°F, inability to tolerate oral intake, significant pain, or comorbidities requiring hospitalization for intravenous antibiotics.
• The choice of antibiotic regimen should be based on the severity of infection, the pathogens presumed to be involved, and the risk factors for major antimicrobial resistance patterns, with consideration of local epidemiological data and resistance profiles 1.
• Complicated diverticulitis with abscess formation may require percutaneous drainage for collections >4 cm, while peritonitis necessitates emergency surgery, and follow-up colonoscopy is recommended 6-8 weeks after resolution to exclude malignancy. Key considerations in the management of acute diverticulitis include:
• The presence of comorbidities, immunosuppression, or signs of sepsis, which may require hospitalization and antibiotic treatment 1.
• The risk of progression to complicated diverticulitis, which is higher in patients with symptoms lasting longer than 5 days, vomiting, systemic comorbidity, high C-reactive protein levels, or CT findings of pericolic extraluminal air or fluid collection 1.
• The potential harms of antibiotic treatment, including the development of antibiotic resistance, and the need for selective use of antibiotics in patients with uncomplicated diverticulitis 1.

From the Research

Management Approach for Acute Diverticulitis

The management approach for acute diverticulitis typically involves medical treatment with antibiotics and a liquid diet. The following points outline the key aspects of management:

• Most cases of diverticular inflammation are mild and require only medical treatment with liquid diet and antibiotics 2, 3, 4.
• Outpatient treatment with oral antibiotics has been shown to be safe and effective for uncomplicated acute diverticulitis, with success rates of over 92% and significant cost savings 2, 4.
• Antibiotic treatment regimens may vary, but common options include metronidazole, ciprofloxacin, and amoxicillin plus clavulanic acid 2, 3, 4.
• The use of antibiotics in uncomplicated diverticulitis is still a topic of debate, with some studies suggesting that antibiotics may not be necessary and may even increase the risk of emergency surgery 5.
• Other therapeutic options, such as mesalazine and probiotics, have been developed in recent years and may be effective in improving symptoms and preventing recurrence of diverticulitis 6.

Treatment Options

The following treatment options are available for acute diverticulitis:

• Oral antibiotics, such as metronidazole and ciprofloxacin, for uncomplicated cases 2, 4.
• Intravenous antibiotics, such as ampicillin and gentamicin, for severe and complicated cases 6.
• Mesalazine and probiotics as alternative or adjunctive therapies for mild-to-moderate uncomplicated cases 6.
• Liquid diet and oral analgesics, such as acetaminophen, to manage symptoms and support recovery 2, 3, 4.

Considerations

When managing acute diverticulitis, the following considerations should be taken into account:

• The severity and complexity of the case, as well as the patient's overall health and medical history 2, 3, 4.
• The potential risks and benefits of antibiotic treatment, including the risk of emergency surgery and the development of antibiotic resistance 5.
• The need for close monitoring and follow-up to ensure effective treatment and prevent complications 2, 3, 4.